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Privacy Practices I acknowledge that Owensboro Dermatology Association, PSC has provided me a copy of their Notice of Privacy Practices, which provides a detailed description of the uses and disclosures allowed, as well as other rights I have regarding my protected health information. ______________________________________________ Patient Name (please print) _____________________________ Patient Date of Birth _______________________________________________ _____________________ Signature of Patient/Guardian Date

Patient Information Please complete all lines. We need this information before we see you. First Name:_________________________________ MI:_____ Last:______________________________________ Billing Address:__________________________City:_______________________ State:_________ Zip:__________ Date of Birth: _____/_____/_____ Sex: ___M ___F Social Security # ______________________________ Marital Status:___________________________________ Home Phone: (______) _________________________ Employer:_______________________________________ Work Phone: (______) __________________________ Primary Language: _______________________________ Have you been here before? ____Yes _____No Student: ____Full Time _____Part Time (Please check one for insurance purposes.) In case of EMERGENCY, who should we notify?_________________________ Phone (______) _________________ Primary Care Physician:__________________________ Phone (______) ________________________________ Referring Physician:_____________________________ Phone (______) ________________________________ How did you hear about us? (Please be specific. For example, tell us which newspaper, yellow page directory, etc.) Newspaper:_______________ Website:_____________ Social Media:__________________ Radio:____________ Yellow pages:______________ Health Fair:_____________ Cancer Screening:_________ Lecture:_____________ Relative/Friend:____________________ Address:___________________________ City/Zip:__________________

Parent or Responsible Party

Name: ________________________________________________________________________________________ Address: ______________________________________________________________________________________ Home Phone: (______)______________ Work Phone: (______)______________ SS#: _______________________ Date of Birth: _____/_____/_____ Sex: ___M ___F Relationship:________________________________ Employer: ____________________________ Address: ________________________________________________

Do we have your permission to: Leave a message on your answering machine at home? ____Yes ____No Leave a message at your place of employment? ____Yes ____No Discuss your medical condition with any member of your household? ____Yes ____No If yes, whom: _______________________________ Relationship: _______________________________________ Patient’s Signature ________________________________________________ Date: _____________________

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* PLEASE PRESENT INSURANCE CARDS TO THE RECEPTIONIST SO COPIES CAN BE MADE*

Insurance Information This information is in regard to the person whose name appears on the insurance card.

Pr imary Ins. Name:_______________________ Secondary Ins. Name: __________________________ Ins. Address:______________________________ Ins. Address:____________________________________ Name of Insured:__________________________ Name of Insured:________________________________ Insured’s SS# ____________________________ Insured’s SS# __________________________________ Insured’s Date of Birth: _____________________ Insured’s Date of Birth: ___________________________ Insured’s ID#:_____________________________ Insured’s ID#:___________________________________ Group#:__________________________________ Group#:________________________________________ Employer Name:___________________________ Employer Name: ________________________________

• In the event of hospitalization or major procedures, we request insurance information for your records. Please furnish the front office staff with your insurance cards.

• I authorize the release of medical information necessary to process this claim and also authorize the payment of medical benefits to the physician.

SIGNATURE: __________________________________________________ DATE: _____________________ Payment Policies In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. PAYMENT IS REQUIRED FOR ALL SERVICES AT THE TIME THEY ARE RENDERED. We accept payment in the form of cash, check, or credit card. In the event of hospitalization or major procedures, our office will file the appropriate insurance. However, before such claims are filed, COVERAGE MAY BE PRE-VERIFIED AND YOU WILL BE ASKED TO PAY ANY UNMET DEDUCTIBLES, NON-COVERED SERVICES AND CO-PAYMENTS. Your signature below signifies your understanding and willingness to comply with this policy. Medicare / Medicaid Authorization PLEASE SIGN SO WE MAY HAVE YOUR MEDICARE AUTHORIZATION ON FILE: I authorize any holder of medical or other information about me to release to the Social Security Administration and Center for Medicare and Medicaid Services, its intermediaries or carrier any information needed for this or any related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment or benefits apply. Supplemental Authorization PLEASE SIGN SO WE HAVE YOUR SUPPLEMENTAL AUTHORIZATION ON FILE: I request authorized MEDIGAP benefits to be made on my behalf for any service furnished to me. I authorized any information needed to determine these benefits payable for related services. PATIENT’S SIGNATURE: ________________________________________ DATE: ____________________

Reason for Appointment Please PRINT CLEARLY, as this will be part of your permanent medical records. NEW RETURNING Referred by: ____________________________________ Room #: __________

Reason for appointment today: _________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ How long has this condition been present? _______________________________________ What are your symptoms, if any (itching, burning, bleeding, etc.)? Please list: ___________ ____________________________________________________________________________ Please list the names of prescription and over the counter medications that have been used to treat your condition (topically–creams/ointments, orally–pills) and their results? Note: You may need to call your pharmacy for names/correct spellings: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Patient: ________________________ DOB: __________ Age: __________ Date: __________ Chart #: ___________

NOTES: ___________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Medication List Please PRINT MEDICATIONS CLEARLY, as this will be part of your permanent medical records. Note: You may need to call your pharmacy to get the names of your medications. Patient: __________________________ DOB: __________ Age: __________ Date: __________ Chart #: ___________ ALLERGIES TO MEDICATIONS: ______________________________________________________________________ ____________________________________________________________________________________________________

MEDICATIONS DATE OF SERVICE REASON FOR TAKING

Preferred Pharmacy: ____________________________ Phone: (______) _____________ City/Zip code:______________

Patient Medical History Please CHECK THE BOX if you have had any of the following medical conditions. Past Medical History:

! Anxiety ! Arthritis ! Asthma ! Atrial fibrillation ! Bone Marrow Transplantation ! Breast Cancer ! Colon Cancer ! COPD ! Coronary Artery Disease ! Depression

! Diabetes ! End Stage Renal Disease ! GERD ! Hearing Loss ! Hepatitis ! High Blood pressure ! HIV/AIDS ! High Cholesterol ! Leukemia ! Lung Cancer

! Lymphoma ! Prostate Cancer ! Radiation Treatment ! Seizures ! Stroke ! Thyroid Problems ! NONE ! Other_______________________ _______________________________

Past Surgical History:

! Appendix Removed ! Bladder Removed ! Mastectomy

(Right, Left, Bilateral) ! Lumpectomy

(Right, Left, Bilateral) ! Breast Biopsy

(Right, Left, Bilateral) ! Breast Reduction ! Breast Implants ! Colectomy: Colon Cancer

Resection ! Colectomy: Diverticulitis ! Colectomy: IBD ! Gallbladder Removed ! Coronary Artery Bypass ! Mechanical Valve Replacement ! Biological Valve Replacement

! Heart Transplant ! Joint Replacement, Knee

(Right, Left, Bilateral) ! Joint Replacement, Hip

(Right, Left, Bilateral) ! Joint Replacement

(within last 2 years) ! Kidney Biopsy (Nephrectomy) ! Kidney Removed (Right, Left) ! Kidney Stone Removal ! Kidney Transplant ! Ovaries Removed: Endometriosis ! Ovaries Removed: Cyst ! Ovaries Removed: Ovarian

Cancer

! Prostate Removed: Prostate Cancer

! Prostate Biopsy ! TURP (Prostate Removal) ! Spleen Removed ! Testicles Removed

(Right, Left, Bilateral) ! Hysterectomy: Fibroids ! Hysterectomy: Uterine Cancer ! NONE ! Other:______________________ _______________________________

Skin Disease History:

! Acne ! Actinic Keratoses ! Asthma ! Basal Cell Skin Cancer ! Blistering Sunburns

! Dry Skin ! Eczema ! Flaking or Itchy Scalp ! Hay Fever/Allergies ! Melanoma

! Poison Ivy ! Precancerous Moles ! Psoriasis ! Squamous Cell Skin Cancer ! Other_______________________

Do you wear Sunscreen? _____Yes _____No If yes, what SPF? ______________ Do you tan in a tanning salon? _____Yes _____No Do you have a family history of Melanoma? _____Yes _____No If yes, which relative(s)? _______________________________________________________________________________ [continued on back] [continued on back]

Social History:

Cigarette Smoking ! Currently Smokes ! Has smoked in the past ! Never smoked ! Former Smoker ! Other____________________

Alcohol Use ! None ! Less than 1 drink per day ! 1-2 drinks per day ! 3 or more drinks per day ! Other_____________________

Family History (Only first degree relatives): ________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________ Review of Symptoms : ! New or recent change in moles ! Trouble taking oral antibiotics ! Enlarged lymph nodes

! Immune system problems ! Rash to bandages or tape ! Rash from oral antibiotics

! Rash from antibiotic ointment ! Other_____________________

A lerts : ! Allergy to adhesive ! Allergy to lidocaine ! Allergy to topical antibiotics ! Artificial heart valve ! Artificial joint replacement ! Blood thinners

! Defibrillator ! MRSA ! Pacemaker ! Require antibiotics prior to a

surgical procedure

! Rapid heart beat with epinephrine

! Are you pregnant or currently trying to get pregnant?

! Other

Thank You One of our goals is to be known for exceptional patient care by providing the best possible service with the use of modern technology and the most effective treatments available. With a combined total of more than 60 years of experience in dermatology, you can feel confident that our dermatology specialists will provide reliability, experience, and quality you can trust. On behalf of our physicians and staff, we would like to personally thank you for allowing us to serve you at one of our three convenient locations: Owensboro Dermatology, Henderson Dermatology, and Advanced Aesthetics.